doctor marketplace & lack of system improvement (delhi summer illness 4)

One of the first things you learn when studying health systems is how imperfect health care markets are — limited time or ability to shop around, massive information asymmetries, etc. It is interesting, then, how very marketplace-like was my experience during my most recent illness episode. It is even more interesting, i think, that this took place within the same corporate hospital system — calling into question the very benefits of such an aggregated system.

.

To briefly recap,  i had (still have, actually) symptoms consistent with chikungunya,  [~chicken-goon-yuh] which is currently breaking out in Delhi but which was not actually confirmed in my case. i managed to visit three doctors in as many days to try to figure out what was going on, which is probably the most ‘shop-around’ approach i have ever taken to a single illness episode. [The desperately curious can read the previous posts on observations from navigating the hospital and health system while being sick: here, here & here.]

.

First, i saw my regular GP. Then, with some urging, i saw a recommended GP. In the interim, i had also scheduled an appointment with a rheumatologist given (a) relevant family history and (b) that my only early symptoms were joint pain , weakness & fatigue — no fever nor rash. In this post, i just focus on the GP visits.

.

The visit to my regular GP on Tuesday led to my being tested (IgM) for chikungunya as well as dengue and malaria (as precautions than really being indicated). i learned on Wednesday morning that the IgM was negative but as my white blood cells were high, i was put on an antibiotic (for a ‘post-viral infection’) and given the obligatory paired antacid + anti-inflammatory as well as calcium for unexplained reasons. i actually don’t think an antibiotic was indicated and was a bit annoyed when i asked if anything else could be causing the joint pain and was told no, which is of course a silly statement since plenty of things cause joint pain, not all of them infectious.

.

In the interim, through the healthcare recommendation grapevine that is Delhi, i learned about another doctor who was recommending a different chikungunya test (and promoting himself as a chikungunya guru). With some urging, i followed-up there was well on Wednesday afternoon, for a (super) special clinic double-feature day.

.

The second GP i saw was in the same corporate hospital system but at a different branch, less than 5 km away. i came in with high hopes for the recommended doctor, most of which were dashed over the course of the short visit. i should note that for this visit, my (male) colleague kindly accompanied and the (male) doctor spent much of the limited attention he gave to either or us (rather than his computer screen or his phone) addressed to my boss. i have never felt so blatantly part of a capitated (pay-by-patient or ‘per head’) system as i did over the course of this week of doctor visits. (A particularly endearing moment came when i asked the doctor to explain my morning’s lab report and why the white blood cells might be elevated — and i was told to google the answer.)

.

The doctor spot-diagnosed me with chikungunya while i was still shuffling in the door, before i was able to sit down and say anything beyond ‘joint pain.’ Perhaps some patients are impressed by this sort of act. i was not. The doctor did very little looking at me and certainly never touched me. i had to really push to get out a description of the specific type of joint pain i was experiencing. Much of the time he addressed himself to a desktop computer screen, where he edited old case notes as mine, such that my print-out included inaccuracies, such as stating that i have no medical allergies (i do, including to some painkillers and anti-inflammatories; moreover, he never actually asked me this question).

.

At first the doctor tried to talk me out of getting another blood test (PCR, this time) since it was expensive (true) and since he was so certain i had chikungunya (ass).

.

He then spent at least a minute of our already poorly utilized 10-minute appointment slot to denigrate my normal GP, in a mock-humble way that acknowledged him as a junior doctor and my usual GP as a senior doctor — but also that he was much more in the trenches at his location, as opposed to her more posh and secluded (<5 km away) location. (Again, recall these are both part of the same hospital system.) He was seeing all the chikungunya cases and she wasn’t, so he knew how to spot-diagnose and which test to run.

.

He then told me that when my test came back positive, as he was sure it would (it didn’t), i should switch doctors. He also poo-pooed her having prescribed me calcium and instead prescribed a multivitamin; he also prescribed a different painkiller + antacid combination for no apparent reason. (i should note that neither doctor actually asked what i was already taking in the way of vitamins before prescribing these to me — i went ahead and bought everything i was prescribed so i could show off the detritus collected for treating a suspected virus over the course of three days.)

20160821_191032

.

Perhaps to some patients, this kind of confidence and blatant salesmanship are appealing and hearken to days of doctors-as-gods. Not to me. So, at a minimum, as a salesman, this doctor has no idea how to read a customer.

.

In fact, his actions seem the very definition of not working in a system or a sign that the system is not working. He could have, instead, said he would call my regular GP and tell her about the extent of the outbreak and about which test to run. Or report it upwards so that there could at least be systemic learning within the hospital system. But, no, he opted to promote himself. And perhaps this is what the ‘system’ incentivizes. But, if so, then what exactly is the benefit of being part of a hospital system if neither my personal records nor basic system- or city-wide learnings can be shared among doctors within and across sites?

.

To return to the initial issue of whether healthcare functions as a market, to the extent that it does, people often rely on quality indicators that may not be directly related to accurate diagnosis or perfect treatment (which are sometimes hard to assess from the patient point-of-view). So, there is cleanliness and comfort of the surroundings (the corporate chain does reasonably well on this). There is whether you feel listened to and respected as a patient (fail). Or, if your doctor isn’t particularly nice (we all secretly want to be treated by Dr. House), you should at least trust him or her but neither GP in this case did anything particularly trust-earning (and did some things that were trust-burning from my way of thinking). There is convenience (yes in terms of online scheduling but no in terms of tracking patients through the system).

.

And, one would think, there would be a benefit of aggregating learnings and best practices across the system — but this appears to not be the case. The corporates may want to think again about how they are fulfilling quality demands.

 

my black folder (delhi summer illness 1)

Since i have lost much of the two months to an extended illness — and since my original reason for getting into public health was unsatisfactory doctor-patient relationships and inadequate assistance helping patients navigate hospital and health systems — it seems to make sense to write about observations and frustrations i had seeking treatment in delhi. i offer this up in the spirit of participant-observation research — not seeking sympathy but trying to point out what is currently not/working. i definitely welcome stories from others seeking health-care in india or elsewhere in the comments: this is a conversation that requires much more attention and probably research.

.

There are three disclaimers. First, i am an extremely privileged patient in Delhi and attend one of the (arguably) best private hospital chains in town. So my case should be taken as something of a ‘best case’ in terms of how i am treated and my experience navigating the system. Second, being sick has made me incredibly grumpy. Third, we are still not entirely sure what i had/have. Given the on-going outbreak of chikungunya in Delhi and my symptom set, this is a plausible guess — but in full disclosure, the test for this and multiple other viruses were negative. While many people in Delhi seem satisfied with being diagnosed with ‘a viral,’ not knowing what i have is hugely frustrating.

.

Whatever i have, ‘joint pain’ does not do justice to the experience — i have had what i would classify as joint aches or pains in the past and this weren’t it. Overnight-onset arthritis begins to get to the point: too painful to walk properly thanks to weak and angry feet, ankle & knee joints; too stiff and painful to make a fist around a bottle of water and elbows too weak to support the bottle anyway; etc. Suffice it to say, rapid aging it isn’t much fun:

giphyLC.gif

. and 

While this whole illness narrative begins a month back, this blog’s story starts today, as i am preparing to go spend a bit of recovery time with my parents in TX and get a second opinion in the process. My mom is scouting for a rheumatologist there (thanks, mom!). She wondered if i could just have my doctor here in Delhi just fax over my notes so far (because the new doc wants to review them before accepting me?). Well, no.

.

Which brings me to my black folder. There is no patient filing system that stays at the hospital for me here in Delhi, though i presume the hospital tracks some sort of information linked to my mobile number in the computers at which people are always tapping (they are very capable of sending via emails the status of my reports or texting to quiz me on my satisfaction).

.

Each visit generates quite a bit of paper for which i am responsible, making me in a very tangible way the curator of my health history. i find this slightly stressful and, again, unlike a lot of patients, i can read and comprehend the vast majority of what is in my file (handwriting aside), can sort through and put it in date order, and so on.

.

At a minimum in a visit to my hospital, there will be the consultation fee receipt, the consultation notes + script and the receipt for medicines purchased. But, likely, there will also be an additional receipt for diagnostic tests to be rendered and then, at some point, the results of that test, whether it is a printout, a scan, an xray, etc. i have to carry all of these. These papers should be ready at all times. For example, vital signs are recorded on my consultation receipt for imperfectly clear reasons. The receipt is then taken out of my possession (ack! i need to photo that for insurance claims!) to be laid before the doctor, who sometimes notes down my vitals on a fresh notepad before beginning the consultation scribbling. More paper.

.

For awhile, one pretends that the soothing seafoam-green envelope proffered by the hospital/clinic along with one set of test results will suffice for the burgeoning ream of paper. But any sort of ongoing illness puts that rapidly to rest. Your makeshift, portable medical record is suddenly and literally coming apart at the seams when you have an extended illness episode, along with your feeling of being able to present your case to another doctor (or to the same doctor, since they have nothing else to which to refer back).

.

Now i have upgraded fro a tattered folder to one of those report-type folders with the plastic sleeves built-in — the kind with a tab on each sleeve, which i have labelled with the month. Each month contains all the the august sleeve is pree-tty full but it is doing the job nevertheless. Mostly.

.

Over the course of this illness, i have worked to keep everything as organized in this folder as possible as a way of imposing some order on the multiple visits, the multiplying symptoms, the confusing test results and their implications for yet more tests. When your fingers aren’t working properly (or more generally when you are feeling like crap), it isn’t very fun to sort through these papers and supple-ly sliding them into the slippery plastic sleeve. It also isn’t particularly fun to clutch this increasingly sweaty folder while you try to navigate your way through jostling patients, especially when your standard elbows-out strategy has been rendered impossible. Hospitals, as i contend in future posts and as others have said before me, aren’t very easy places to be sick. And, at least in Delhi, to be without a chaperone/Moses.

And, .

But one does carry one’s plastic folder to place before the doctor: see, i am a good patient. A conscientious patient. You can tell because my files are in order that i will probably try to follow your prescriptions and that i get what is going on here. And that this whole thing has been ‘going on’ far too long. We can both see that, right?

.

i can’t pinch my fingers properly to pull the sheets out for you but here, this is the August sleeve. You can just pull them out and… sure, spread them all over the desk. Gah, this is the same feeling as when you had the immigration officer with your finger marking the visa page and they insist on closing the passport booklet and then casting you disgusted glances when s/he can’t find your visa. But worse.

.

Yes, i could point(-ish) you to what you’re asking about… but rifling through will work eventually as well. Taking a call while you’re looking and while i’m sitting here will definitely help as well. Oh, you’re done? Then, sure, sweep everything back into a haphazard pile and then just… OK, bypass the plastic sleeve. Just close the cover over the whole mess. That’s cool. i just spent 3 minutes explaining how painful it was to work my fingers and i assume you were listening because you prescribed multiple blood-tests and several medications of questionable necessity. You even took notes. Including those notes, altogether, that’s four more pieces of paper i am going to acquire in the next hour. To add to that mess you just made of my medical history. To clutch-ish until i get home and then sort the whole damn thing again after the next painkiller to show the next half-interested doctor that i am a good patient, it’s just that the illness isn’t going away.

.

Look, it’s all here in my folder. Dammit. The folder tied the whole thing together.